Exam 2 (Ch 7, 13-19, 29, 33, 37-39) Practice Questions Flashcards

Question

An oncology nurse is analyzing a patient’s strengths and finds the patient is well educated, learns quickly, and is resilient. In which phase of the nursing process will the nurse use this information? A. Diagnosing B. Evaluating C. Planning D. Implementing

Answer 1

A RATIONALE: a. Assessing for strengths and weaknesses is the first step of the nursing process, which has been completed. Next, the nurse clusters cues and develops diagnoses that give rise to interventions. Evaluating the plan is followed by completing or modifying the plan.

Answer 2

A RATIONALE: a. The case represents a concrete example of how students develop situational awareness and how that awareness develops with experience. Cognitive load management occurs in many ways; the use of mental images may not facilitate cognitive load management. Although an environmental scan is important, it is generally not documented in the EHR. Patient satisfaction is not the priority when completing the initial assessment; rapport formation, solid assessments, and good patient outcomes are associated with patient satisfaction.

Answer 3

B RATIONALE: b. Reflection drives the clinical judgment cycle and allows for the integration of new knowledge that will inform future situations. Reflection is as important in Tanner’s model as the other elements of noticing, interpreting, and responding. The focus of the model is the development of clinical judgment, rather than rapid decision making; as clinical judgment is developed, decision making improves and may lead to better patient outcomes. Tanner’s model is cyclic, not linear; although bias may be addressed as part of the development of clinical judgment, it is not the focus.

Answer 4

A,B,D,E RATIONALE: a, b, d, e. Nurses in the United States must pass NCLEX prior to being issued a license to practice as a professional nurse. To help students achieve this goal, nurse educators model course exams on the NCSBN’s NCLEX test plan in terms of content and style. Understanding the why (rationale for actions) is often helpful when students are engaged in studying, working to apply the information they have learned, and developing test-taking strategies. There is overlap between the models and processes identified as foundational to nursing education, which demonstrates the importance of fundamental concepts. A deep understanding of theoretical and philosophical models is not necessary for student nurses.

Answer 5

C RATIONALE: c. The definition of a competency included in the Nursing: Scope and Standards of Practice (ANA, 2021) identified includes knowledge, skills, abilities, and judgment. Competency-based education is more than a checklist and often requires repeated exposure to concepts for mastery in a variety of contexts. Although the delivery of education can flex to meet the needs of students, testing is standardized to address core competencies. Competency-based education is very direct and concrete; the development of competence requires clinical judgment.

Answer 6

C RATIONALE: c. Each nursing student is in charge of their learning, including integrating feedback from exams, clinical experiences, simulations, and other assignments—reflecting on what has been learned and integrating new learning. Adaptability is key. Classroom and clinical learning presents information in myriad ways and in different settings. Students should learn what they can from each situation and adapt their studying style as needed. Nursing knowledge, like patient care, is rarely straightforward and clear. Picking up on cues, emphasizing the correct element, answering the question being asked, and maintaining a person-centered focus that is individualized and nuanced requires practice and time. Students must give themselves the space and grace needed to learn and apply information in various situations. There is a reciprocity in learning that requires and inward and outward combination. Engagement with others and the environment is essential for shaping thinking and development of clinical judgment.

Answer 7

A RATIONALE: a. The instructor is reminding the student that all data must be validated. Questioning the use of the word “fine” allows the nurse to determine if this is a social and reflexive response, and there may be another need the nurse can meet. Concluding that the patient does not trust the student is premature and is based on an invalidated inference. Saying “That’s good to hear” and asking the student to describe the care provided is incorrect because it accepts the invalidated inference. Telling the student to reassess the patient because they were admitted with a serious problem is incorrect because it is possible that the condition is resolving.

Answer 8

D RATIONALE: d. A quick priority assessment (QPA) is a short, focused assessment to obtain the most important information first. A comprehensive initial assessment is performed shortly after admission. The time-lapsed assessment is used to compare a patient’s current status to baseline data obtained earlier.

Answer 9

A, E, F RATIONALE: a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient’s responses to actual and potential health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient’s health status, the ability to manage their own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient’s strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the finding(s) to the health care provider or collaborate with other health care professionals where indicated. Citing hospital policy or student learning is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the main reason for a nursing history and assessment. The assessment augments the medical examination but is not performed to check its accuracy.

Answer 10

D RATIONALE: d. Perform a focused skin assessment for the new problem, documenting the current date. The initial assessment was entered in the permanent health record, correct at the time, and cannot legally be rewritten. An emergency assessment is performed for a life-threatening problem.

Answer 11

B RATIONALE: b. Once a nurse learns what constitutes the minimum data set, it can be adapted to each patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice individualize their questions to each patient and situation. When using a standard facility assessment tool the nurse must still use critical thinking to individualize questions or follow up on patient information.

Answer 12

A, C, D, E RATIONALE: a, c, d, e. Subjective data are information perceived only by the affected person. Examples of subjective data are feeling nauseated, anxious, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Examples of objective data are fever or 101°F or edema.

Answer 13

D RATIONALE: d. The patient has the right to privacy and to determine who will be present during the nursing history and exam. The nurse does not presume the patient’s preference, as the decision belongs to the patient, not their spouse.

Answer 14

B RATIONALE: b. Gordon’s functional health patterns begin with the patient’s perception of health and well-being and progress to data about nutritional–metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow’s model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

Answer 15

C RATIONALE: c. The nurse validates assessment findings that deviate from normal patterns or are unsupported by other data. Should the initial measurement be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse must be sure that all data are accurate prior to documenting and reporting. If there is a question about accuracy, the data should be validated before documenting.

Answer 16

B RATIONALE: b. When assessment findings reveal a critical change in the patient’s health status, the nurse reports the data (verbally) immediately. The nurse verifies the BP and notifies the health care provider, who may prescribe withholding blood pressure medications, assessment of orthostatic vital signs, among other actions. There is no indication the patient needs to lie flat at this time.

Answer 17

B RATIONALE: b. While the patient is confused, it is most important to clearly describe the behavior for comparison to past and future behavior. Citing the actual year and events (orientation to time and place) provides context; “patient confused” is open to misinterpretation. Garbled speech refers to speech that is unclear; the patient may have difficulty with pronunciation or speak slowly, which is not necessarily reflective of confusion.

Answer 18

C RATIONALE: c. The triage nurse screens patients to determine the extent and severity of their problems. They use highly specialized nursing knowledge and clinical reasoning and make clinical judgments to prioritize who must be seen immediately and who can wait. Patients in the ED are stabilized and transferred to the appropriate level of care; therefore, daily care, assistance with ADLs, planning for return home, and providing interventions are not part of the triage nurse’s role. Should the patient need emergency interventions, the triage nurse moves the patient to the appropriate area in the ED.

Answer 19

D RATIONALE: d. The nurse uses Maslow’s hierarchy of needs to prioritize assessing the patient with hypoxemia, manifested by a pulse oximetry reading of 89%. The postoperative patient is reporting moderate pain; the patient with pneumonia has normal WBCs; the adolescent patient with a burn to the face is stable for discharge. These patients can be seen as soon as possible.

Answer 20

A,C,D RATIONALE: a, c, d. The OLD CARTS mnemonic refers to Onset: “When did your symptom(s) begin”?. Location: “Where is the symptom”?. Duration: “Is it episodic or constant?” or “How long does it last”?. Characteristics: “How would you describe it?.” Alleviating and Aggravating factors: “What makes it better or worse?.” Relieving factors: “What makes it better?.” Treatments: “Have you tried anything to make it better?.” Severity: “On a scale of 1–10, with 1 being the lower number, how serious is the symptom?.”

Answer 21

C RATIONALE: c. Children and people with decreased mental capacity or impaired verbal ability should be encouraged to respond to interview questions as best as they can. This communicates support of the patient’s autonomy, expression of their needs, and respect for their abilities. The information is then validated with family members or guardians as appropriate.

Answer 22

B RATIONALE: b. The nursing physical assessment involves the examination of all body systems in a systematic manner, commonly using a head-to-toe format called the review of systems (ROS). This assessment begins at the top of the body with the neurologic system and moves downward.

Answer 23

B,D,F RATIONALE: b, d, f. Diagnosing includes identifying actual or potential health problems for individuals, groups, or communities; identifying factors that contribute to or cause health problems (etiologies); and identifying resources or strengths the individual, group, or community can draw on to prevent or resolve problems. The nurse assesses and collects patient data in the assessment step and develops the care plan during the planning phase of the nursing process.

Answer 24

B,C,D,E RATIONALE: b, c, d, e. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent or interdependent nursing interventions. These include Impaired gas exchange, supported by low oxygen saturation; Impaired Respiratory System Function; Altered breathing pattern, supported by dyspnea and tachypnea; and Impaired Thermoregulation. Pneumonia is a medical diagnosis.

Answer 25

B RATIONALE: b. When a possible problem exists, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion, “no problem,” indicates no nursing response is required. When an actual problem is identified, the nurse continues using the steps of the nursing process by planning, goal setting, implementing, and evaluating care to resolve the problem. A clinical problem other than nursing diagnosis requires a collaborative approach with the appropriate health care professionals.

Answer 26

B RATIONALE: b. The etiology, sensory and motor deficits, identifies the contributing or causative factors of the problem. The problem, “Impaired Tissue Integrity: Impaired Skin Integrity,” states the undesirable health condition, life processes, or human response. The phrase, “Signs and symptoms: non-blanchable reddened areas on heels and back,” contains the defining characteristics of the problem.

Answer 27

D RATIONALE: d. Difficulty Coping: Impaired Acceptance of Health Status is a nursing problem, falling within the scope of independent nursing practice. Collaborative and interdisciplinary problems are resolved through a teamwork approach with other health care professionals. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

Answer 28

A RATIONALE: a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared within the same class or category. When interpreting the significance of a patient’s blood pressure reading, the nurse uses normative values for the patient’s age group, race, and illness category and compares these to the patient’s recent results. Identifying the reason for deviation from a norm gives direction to the etiology of a health problem (e.g., insufficient knowledge, nutrition, stress, and coping, or other).

Answer 29

A RATIONALE: a. Patient health problems are derived from clusters of related data and patterns, rather than a single cue. The nurse determines if this is the patient’s usual bowel pattern, or whether an underlying reason exists for the lack of a bowel movement. Constipation is a health problem the nurse can resolve with independent or interdependent nursing actions.

Answer 30

D RATIONALE: d. Using the nursing process, the nurse first assesses the patient’s knowledge base; this also confirms the accuracy of the problem statement. Problem statements with unclear etiologies may lead to inappropriate, erroneous, or unhelpful interventions. If the patient has difficulty affording medications or is experiencing side effects, a collaborative problem can be resolved jointly by the nurse, social worker, and health care provider.

Answer 31

D RATIONALE: d. A correctly written two-part problem statement includes the health problem and the etiology or cause. The problem statement and etiology should avoid signs and symptoms, medical diagnoses, and something that cannot be changed. Inability to maintain marriage and anger issues do not identify the underlying cause of the problem and may themselves reflect the true problem. Psychosis is a medical diagnosis, which should not be used to support a patient problem.

Answer 32

D RATIONALE: d. Correctly written problem statements contain a problem the nurse can treat with independent or interdependent interventions, a clearly stated etiology or cause of the problem, and supporting signs and symptoms. Option (a) may be more easily resolved with the problem statement, knowledge deficiency. Option (a) further states the tube feeding is the underlying cause of the problem; it is a factor that cannot be changed. Option (c) is written in terms of needs and not an unhealthy response. Option (e), while written in three parts, places blame or implies negligence, which is legally inadvisable and should be avoided. A clear etiology is not stated in option (e), impeding direction for appropriate interventions or outcomes.

Answer 33

C RATIONALE: c. The nurse clusters the data that demonstrates the patient’s (actual) inability to perform bathing and grooming. For that reason, a “potential problem” or “risk” is not appropriate. There is no evidence the patient lacks motivation, and paralysis is not a problem the nurse can resolve.

Answer 34

D RATIONALE: d. A cue denotes significant data or “red flags,” that, when occurring in a pattern or cluster, point to the existence of a health problem.

Answer 35

B RATIONALE: b. After the health problem is developed, the nurse begins the planning phase of the nursing process, which includes goal development. Elevating the heels and teaching the patient to turn are interventions used during the implementation phase. Delegating an assessment to the AP is an incorrect activity; assessment falls within the role and scope of practice of the professional nurse. In addition, the nurse must perform the skin assessment to develop the problem and plan care.

Answer 36

C RATIONALE: c. After clustering the data, the nurse analyzes the data and formulates a nursing diagnosis. Interventions are based on and developed after goal setting. Nursing judgments are outcomes based on critical thinking and clinical reasoning. A concept map is a diagram or pictorial representation of the (student) nurse’s understanding of the interactions and relationships of the patient’s problems and plan of care.

Answer 37

B RATIONALE: b. The nurse continues gathering data, determining the presence of a problem of grief, impaired coping, etc., by determining the underlying cause of the tears. If the patient received news that a biopsy was free from cancer, perhaps no problem exists. If the patient was told they have a terminal illness, the nurse can continue to gather data and plan to support the patient’s physical and emotional needs.

Answer 38

B,C,D RATIONALE: b, c, d. During the outcome identification and planning step of the nursing process, the nurse, patient, and family collaborate to establish priorities and identify and write expected patient outcomes. The nurse selects evidence-based nursing interventions, and communicates the care plan. These steps may overlap; however, formulating and validating nursing diagnoses are typically performed during the diagnosing step. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

Answer 39

C RATIONALE: c. One of the published standards and requirements for accreditation and certification required by The Joint Commission is to “improve staff communication.” Communicating the plan of care with the patient and oncoming and off going nurses meets this goal. Using patient identifiers relates to the goal of safely identifying patients, checking high-risk medications relates to decreasing medication errors, and obtaining a patient sitter relates to general safety and fall reduction.

Answer 40

B, D,E RATIONALE: b, d, e. Informal planning is a link between identifying a patient’s strength or problem and providing an appropriate nursing response, often while rearranging priorities. Examples of this include the nurse integrating assessment for postpartum depression during patient care, providing a therapeutic presence for a patient who received bad news, or reassessing a patient for pain during rounding. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

Answer 41

B RATIONALE: b. Because basic needs must be met before a person can focus on higher ones, Maslow’s hierarchy of needs sets the priorities as: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. Answer (b) is an example of a physiologic need, (a and d) are examples of a self-esteem need, and (c) is an example of a love and belonging need.

Answer 42

A,C,F RATIONALE: a, c, f. Critical pathways represent a sequential, interdisciplinary, minimal practice standard for a specific patient population, that provide flexibility to alter care to meet individualized patient needs. They provide the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

Answer 43

D RATIONALE: d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient’s achievement of new skills; and (c) is an outcome describing a physical change in the patient.

Answer 44

B RATIONALE: b. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person’s ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone’s ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

Answer 45

B RATIONALE: b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: “Offer the patient 60 mL fluid every 2 hours while awake.” Correct: “The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/25.” The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include “know,” “understand,” “learn,” and “become aware.”b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: “Offer the patient 60 mL fluid every 2 hours while awake.” Correct: “The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/25.” The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include “know,” “understand,” “learn,” and “become aware.”

Answer 46

B RATIONALE: b. The terms goal, objective, and outcome are often used interchangeably to refer to the expected conclusion to the patient’s health problem or expectation. Nurses use the phrase expected outcomes to refer to the more specific, observable, and measurable changes. Options a, c, and d are stated as interventions, rather than outcomes.

Answer 47

C RATIONALE: c. A concept map care plan is a diagram synthesizing patient problems and interventions. The nurse’s ideas about patient problems and treatments are the “concepts” that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and provide a holistic view of the patient’s situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

Answer 48

B RATIONALE: b. A nurse-initiated intervention is related to the nursing diagnosis and projected outcome. It is an autonomous action based on scientific rationale. The physician or health care provider uses a physician-initiated interventions or order in response to the medical diagnosis: nurses execute these interventions safely and effectively. Collaborative interventions are initiated by other providers including pharmacists, respiratory therapists, or physician assistants.

Answer 49

A RATIONALE: a. Performing a focused assessment is an independent nurse-initiated intervention, not requiring a prescription from or intervention by the health care provider, advanced practice nurse, or nutritionist.

Answer 50

A,D,F RATIONALE: a, d, f. During the implementing step of the nursing process, nursing actions that were formulated during the planning process are carried out. The purpose of the implementation phase is to assist the patient in achieving valued health outcomes, for example promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient’s nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing/analyzing step.

Answer 51

B RATIONALE: b. The Nursing Interventions Classification (NIC) Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

Answer 52

A RATIONALE: a. Standard orders empower the nurse to initiate actions ordinarily requiring the order, prescription or supervision of a health care provider. The nurse first assesses whether the patient has already received the vaccine. The standing order is a valid prescription given to cover common, recurring actions the nurse can use when indicated.

Answer 53

C,D,F RATIONALE: c, d, f. Nurse-initiated interventions, or independent nursing actions, include nurse-prescribed interventions resulting from their assessment of patient’s actual or potential health problems. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.

Answer 54

B RATIONALE: b. Before implementing any nursing action, the nurse returns to the first step of the nursing process, reassessing whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.

Answer 55

A RATIONALE: a. Student nurses should notify their nursing instructor or nurse preceptor if they believe they lack any competencies needed to safely implement the care plan. Once educated and technically prepared, the nursing student may perform a dressing change.

Answer 56

C RATIONALE: c. When a patient rejects the care plan, the nurse works to identify the underlying barriers. If the nurse determines that the care plan is adequate, the nurse works with the patient to formulate mutually developed goals and interventions.

Answer 57

B,C,E,F RATIONALE: b, c, e, f. AP assist the RN to provide care as delegated by and under their supervision. Typical tasks delegated include actions for stable patients (e.g., vital signs hygiene, bed-making, ambulating patients, and helping to feed patients). Performing the initial patient assessment and administering medications are the responsibility of the RN.

Answer 58

D RATIONALE: d. When time constraints and safety permit, priorities identified by the patient as most important are completed first. Washing the patient’s hair and assisting with hygiene put the patient first, setting the tone for an effective nurse–patient partnership.

Answer 59

A,D,C RATIONALE: a, b, c. The nurse reassesses the patient’s knowledge and acceptance of the plan of care, including the level of pain the patient finds acceptable. Using a dry-erase board and hourly rounding further communicate and reinforce the care plan. The nurse develops a compassionate and trusting relationship with the patient; the nurse and patient mutually determine the plan for pain management, not their family.

Answer 60

A RATIONALE: a. Care bundles are sets of evidence-based interventions that, when performed together and consistently, improve the process of care and patient outcomes. Discarding sterile drapes from the insertion kit circumvents this process.

Answer 61

D RATIONALE: d. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the care plan. As the plan is not completely working as written, continuing without further assessment is contraindicated. It is premature to terminate the care plan before the outcome is met. The student may need additional support and time to reach the outcome.

Answer 62

B RATIONALE: b. The nurse documents the goal has not yet been achieved and also suspects the patient has not adhered to the prescription, perhaps due to frequent urination or other side effects. The nurse further assesses the patient’s understanding of the medication’s purpose and effects, understanding of the disease process and complications.

Answer 63

A,C,E RATIONALE: a, c, e. Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent. Standards would include monitoring patient status every hour, repositioning a patient on bed rest every 2 hours, and administering pain medication prescribed by the health care provider. Using intuition to troubleshoot patient problems, becoming a nurse mentor to a student nurse, and becoming involved in community nursing events are not included in patient care standards.

Answer 64

D RATIONALE: d. The two-part evaluative statement includes a decision about how well the outcome was met, along with patient data or behaviors that support this decision. Outcomes may have been met, partially met, or not met. The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the care plan, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

Answer 65

C RATIONALE: c. Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient’s achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

Answer 66

A RATIONALE: a. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient’s achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

Answer 67

D RATIONALE: d. The evaluative statement should contain a date; the words “outcome met,” “outcome partially met,” or “outcome not met”; and the patient data or behaviors that support this decision. The other answer choices are incomplete statements.

Answer 68

A,C,E RATIONALE: a, c, e. Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for confidentiality of care with transparency for the patient and designated individuals, rather than secrecy is used.

Answer 69

B RATIONALE: b. Quality by inspection focuses on finding deficient workers and removing them. Concurrent evaluation uses direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met. Retrospective evaluation may use post discharge questionnaires, patient interviews (by telephone or face to face), or chart review (nursing audit) to collect data. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment thriving on teamwork, with people sharing the skills and lessons they have learned.

Answer 70

B RATIONALE: b. Unlike quality assurance, quality improvement (QI) is internally driven. QI focuses on patient care rather than organizational structure and processes rather than people, and has no end points. Its goal is improving quality rather than assuring quality. Process evaluation and outcome evaluation are types of quality-assurance programs.

Answer 71

B RATIONALE: b. Quality improvement or continuous quality improvement involves systematic, continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. Quality-assurance programs enable nursing to be accountable for the quality of nursing care. Making changes without gathering needed data may prove unsafe or a waste of time. Reporting to the nurse manager does not reflect professional commitment to improving processes.

Answer 72

C RATIONALE: c. Crucial Conversations for Healthcare, addresses “undiscussable” communication breakdowns and gaps that can result in patient harm, medical errors, and staff turnover. When nurses feel unsafe to report problems or are not heard, dangerous shortcuts, incompetence, and disrespect may ensue. Threatening the nurse with reporting them is unprofessional and inconsistent with the crucial conversations. Providing a handout is passive aggressive and does not clearly relate the medication error to this concept.

Answer 73

E,B,A,C,D RATIONALE: e, b, a, c, d. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what the nurse looks for during evaluation, that is, expected patient outcomes); (2) collecting data to determine whether these criteria and standards are met; (3) interpreting and summarizing findings; (4) documenting your judgment; and (5) terminating, continuing, or modifying the plan.

Answer 74

C RATIONALE: c. When an outcome is not achieved, the nurse can (1) delete or modify a diagnosis; (2) revise the diagnosis, making it more realistic; (3) adjust the time criteria, or (4) modify the nursing interventions. This outcome was not successfully met; further assessment and revision is indicated. It is inappropriate for the nurse to designate a family member to take over insulin administration without additional assessment and patient permission.

Answer 75

B RATIONALE: b. Kripalu, or “gentle yoga,” focuses on relaxation and coming into balance. Ashtanga focuses on synchronizing breath with a fast-paced series of postures. The nurse should not discourage the use of yoga in patients who are healthy enough to participate. Yoga is not contraindicated in patients with controlled high blood pressure. Post-MI patients should resume activity with guidance from the health care provider.

Answer 76

C RATIONALE: c. Many nurses are expanding their clinical practice by incorporating CHAs. Although many CHAs seem safe, some therapies have led to harmful or lethal outcomes. Patients should seek guidance from the provider. Many patients use these types of therapies as outpatients and choose to continue them as inpatients. Most complementary and alternative therapies predate modern medicine; it was not until recently that nursing and medical schools began to teach about their use.

Answer 77

A,B,E RATIONALE: a, b, e. With CHAs, mind, body, and spirit are integrated and together influence health and illness; illness is a manifestation of imbalance or disharmony. Allopathic beliefs include: The main causes of illness are considered to be pathogens (bacteria or viruses) or biochemical imbalances, curing seeks to destroy the invading organism or repair the affected part, and emphasis is on disease and high technology. Drugs, surgery, and radiation are among the key tools for dealing with medical problems. According to allopathic beliefs, health is the absence of disease.

Answer 78

A RATIONALE: a. Patient participation in guided imagery (a CHA) with the administration of pain medications (allopathy) is an example of integrative care. Integrative care uses some combination of allopathic medicine and CHAs.

Answer 79

B,D,E,F RATIONALE: b, d, e, f. Naturopathic medicine is a system of medicine and a way of life. Emphasis is on patient responsibility, patient education, health maintenance, and disease prevention. Its principles include minimizing harmful side effects and avoiding suppression of symptoms, educating patients and encouraging them to take responsibility for their own health, treating the whole person, preventing illness, believing in the healing power of nature, and treating the cause of a disease or condition rather than its symptoms.

Answer 80

A,B,C,F RATIONALE: a, b, c, f. Chiropractors may combine the use of spinal adjustments and other manual therapies with several approaches including heat and ice, electrical stimulation, relaxation techniques, rehabilitative and general exercise, counseling about weight and diet, and using dietary supplements. Chiropractors do not prescribe medication or perform invasive procedures.

Answer 81

B RATIONALE: b. THC is the psychoactive substance found in marijuana. Marijuana used for health problems or recreational use may be legal based on state law. However, for persons employed in safety-sensitive positions, such as nursing, the presence of THC or its constituents may pose a threat to health and safety. A positive test for THC may result in disciplinary action by an employer.

Answer 82

C RATIONALE: c. Meditators are encouraged to let distractions come and go naturally without judging them. Assuming a comfortable posture lying down, sitting, standing, or walking is appropriate, as is focusing attention on a mantra, object, or breathing. The individual should not suppress distracting or wandering thoughts; instead, they should gently bring attention back to focus.

Answer 83

B RATIONALE: b. Commonly used essential oils in a health care setting are ginger or peppermint for nausea and lavender or chamomile for insomnia.

Answer 84

A RATIONALE: a. Energy healing is focused on pain that lingers after an injury heals as well as pain complicated by trauma, anxiety, or depression. Nutritional and herbal remedies treat all chronic pain, but especially abdominal discomfort, headaches, and inflammatory conditions, such as rheumatoid arthritis.

Answer 85

A,B,D,E RATIONALE: a, b, d, e. Holistic nursing is based on the philosophy of holism, which incorporates the mind, body, and emotions. Further, the interrelationships of the bio-psycho-social-spiritual dimensions of the person are greater than and not separate from their parts. Conventional scientific models focus on treatment of health conditions, individual organs, or organ systems rather than the whole dynamic being as part of their environment. Surgical procedures do not address body, mind, and emotions.

Answer 86

B,C,D,E,F RATIONALE: b, c, d, e, f. Creating an optimal sleep environment for deep, restorative rest includes establishing a regular sleep–wake schedule and minimizing light and noise. Music can promote relaxation and increase sleep quality, as can relaxation exercises.

Answer 87

A RATIONALE: a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

Answer 88

B RATIONALE: b. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.

Answer 89

C,B,A,E,D RATIONALE: c, b, a. e. d. The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). The patient is kept NPO, as prompt surgical repair will be needed. After the patient has received attention, the nurse documents all assessments and interventions in a timely manner.

Answer 90

C RATIONALE: c. Wounds cause emotional as well as physical stress.

Answer 91

A,B,D,E,F RATIONALE: a, b, d, e, f. Careful hand washing (medical asepsis) is the most important. The nurse will use sterile dressings and supplies and promote intake of vitamins, zinc, and protein. Depending on the site of the wound and condition of the patient, bedrest may be indicated.

Answer 92

A,C,E RATIONALE: a, c, e. Hemostasis occurs immediately after the initial injury, and exudate occurs in this phase as plasma and blood components leak out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

Answer 93

C,F RATIONALE: c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2020). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

Answer 94

A,D,E RATIONALE: a, b, e. The correct procedure for cleaning an open wound with edges that are not approximated is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 inch beyond the end of the new dressing, and (6) clean to at least 2 inches beyond the wound margins if a dressing is not being applied.

Answer 95

B,C,D,F RATIONALE: b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. A low albumin level signals a risk for poor wound healing related to malnutrition. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development; however, taking time to formulate responses is consistent with normal aging. This patient’s BUN and creatinine are within normal range; however, dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

Answer 96

C RATIONALE: c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

Answer 97

C RATIONALE: c. Negative pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

Answer 98

B RATIONALE: b. A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red–pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. Dark maroon or purple wounds with intact skin represent deep tissue injury. Red granulation tissue is present in stage 3 or 4 pressure injuries that are healing. A blanchable, red area is a stage 1 pressure injury.

Answer 99

B RATIONALE: b. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and dressing changes only when necessary (or based on product manufacturer’s recommendations). To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigation. The eschar found in black wounds requires debridement (removal) before the wound can heal.

Answer 100

D RATIONALE: d. To prevent pressure injuries, the nurse teaches the UAP to cleanse the skin routinely and whenever soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse educates the UAP to minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

Answer 101

A RATIONALE: a. To measure the depth of a wound, the nurse should perform hand hygiene and apply gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound’s margin; and remove the swab and measure the depth with a ruler.

Answer 102

D RATIONALE: d. The patient is at very high risk for pressure injury. This patient responds only to painful stimulate (1); is occasionally moist (3); is bedridden (1); has not eaten (1), and requires maximum assistance for moving (1) for a total of 7 points. The Braden scale scoring is: a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to 14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk (Braden & Maklebust, 2005). In addition, nurses use clinical judgment to incorporate risk factors and/or other health problems into preventative interventions.

Answer 103

A RATIONALE: a. Wound dehiscence is the partial or total separation of wound layers as a result of excessive stress on unhealed wounds. Patients at greater risk include obese or malnourished individuals; tobacco smokers; and those taking anticoagulants, who have infected wounds, or who experience excessive coughing, vomiting, or straining (Hinkle & Cheever, 2018). An increase in the flow of (serosanguineous) fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The patient may say that “something has suddenly given way.”

Answer 104

A. RATIONALE: a. Example: Weight = 68 kg, height = 165 cm (1.65 m), Calculation: 68 ÷ (1.65)2 = 24.98

Answer 105

A,C,E RATIONALE: a, c, e. Criteria to consider when evaluating patient feeding tolerance include absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits.

Answer 106

A RATIONALE: a. To feed a patient with dementia, the nurse should stroke the underside of the patient’s chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

Answer 107

B RATIONALE: b. Food from home that the patient enjoys may stimulate them to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what they must eat is no guarantee that they will comply.

Answer 108

C RATIONALE: c.The nurse should provide a 30-minute rest period prior to mealtime to promote better swallowing. The nurse alternates solids and liquids when feeding the patient; sits the patient upright or, if on bedrest, elevates the head of the bed at a 90-degree angle; and initiates a nutrition consult for diet modification and food size and/or consistency. Straws are avoided in patients with dysphagia. Assessing breath sounds will help detect aspiration but not prevent it.

Answer 109

A,B,F RATIONALE: a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access, motility disorders, intractable diarrhea, impaired absorption of nutrients from the GI tract, and when oral intake has been or is expected to be inadequate over a 7- to 14-day period. PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet with an increased need for calories and nutrients. Oral intake is the best method of feeding; the second-best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.

Answer 110

A RATIONALE: a. The first action of the nurse when a patient has nausea is to remove the tray, which may have noxious odor, from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect

Answer 111

A RATIONALE: a. The need for B vitamins is increased in alcoholism because these nutrients are used to metabolize alcohol, thus depleting their supply. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.

Answer 112

A RATIONALE: a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air. If drainage is present, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry

Answer 113

D RATIONALE: d. Tolerance to a diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.

Answer 114

D RATIONALE: d. Radiographic examination is the most accurate method to validate tube placement in the stomach. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual volume amount does not confirm placement.

Answer 115

B,C,D,F RATIONALE: b, c, d, f. Due to age-related changes, caloric needs of the body decrease; however, the need for nutrients, including protein, calcium, vitamin B12, and vitamin D increase. If tooth loss and periodontal disease occur, adequate nutritional intake may become more difficult. An increase in fiber and fluid intake can relieve constipation related to decreased peristalsis. Older adults are also prone to dehydration related to loss of thirst sensation. Loss of taste between sweet and salty occurs with a preference for sweets. Dietary restrictions related to chronic illness, limited income, isolation, and age-related physiologic changes place persons in this age group at risk for malnutrition.

Answer 116

A,B,D,E RATIONALE: a, b, d, e. Test results for hemoglobin (normal = 12 to 18 g/dL): decrease indicates anemia. Results for hematocrit (normal = 40% to 50%): decrease indicates anemia; increase indicates dehydration. Serum albumin and prealbumin tests for malnutrition and malabsorption will be decreased, as will transferrin and blood urea nitrogen. Elevated lymphocytes may indicate infection.

Answer 117

A RATIONALE: a. To remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. The stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and, if unsuccessful, the tube should be replaced.

Answer 118

C RATIONALE: c. Patients taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have increased risk for excessive bleeding and may requiring surgery to be postponed. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breastfeeding do not adversely affect the outcomes of surgery.

Answer 119

C RATIONALE: c. Mechanically altered diets provide adequate in calories and nutrients and contain chopped, ground, or soft foods. Liquid diets are generally used as transitional diets when eating resumes after acute illness, surgery, or parenteral nutrition. Clear-liquid diets are inadequate in calories, protein, and most nutrients; progression to more nutritious alternatives is recommended as soon as possible. Full-liquid diets include clear liquids plus milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes in addition to clear liquids. A high-calorie, high-protein supplement is recommended if a full-liquid diet is used for more than 3 days.

Answer 120

D,E,F RATIONALE: d, e, f. A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a sterile urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collection drainage bag may not be fresh urine and could result in an inaccurate analysis.

Answer 121

A,C,E RATIONALE: a, c, e. Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.

Answer 122

A,C,E,F RATIONALE: a, c, e, f. It is recommended that a healthy adult drink six to eight 8-oz glasses of fluid daily, dry the perineal area after urination or defecation from the front to the back, and observe the urine for color, amount, odor, and frequency. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse. Observing urine characteristics will not prevent a UTI; however, this observation may help a patient notice an infection.

Answer 123

A RATIONALE: a. Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.

Answer 124

A RATIONALE: a. Because of the length of the male urethra and need to insert the catheter 6 to 8 inches, it is more prone to injury. The nurse inserts the catheter for a female patient 2 to 3 inches. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI.

Answer 125

C RATIONALE: c. Post procedure continuous bladder irrigation, in the presence of hematuria, prevents stasis of blood and clot formation potentially obstructing urine output. In the absence of hematuria, clots or debris, natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction (Gould et al., 2009; SUNA, 2015).

Answer 126

A,C,F RATIONALE: a, c, f. Urinary diversion involves the surgical creation of an alternate route for excretion of urine. When caring for a patient with a urinary diversion, the nurse should measure the patient’s fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.

Answer 127

D RATIONALE: d. The stoma should appear pink to red, shiny, and moist; a dark brown or purple-blue stoma may reflect compromised circulation. The nurse contacts the health care provider immediately. A urostomy is incontinent; urine leakage is expected.

Answer 128

B RATIONALE: b. Factors associated with urinary retention include medications, an enlarged prostate, and vaginal prolapse. Assist the patient to void when the patient first feels the urge. Assessing for residual urine will not promote voiding; rather, it will determine the volume of urine in the bladder. Cold water would cause the patient to tighten their muscles.

Answer 129

A RATIONALE: a. The nurse palpates and auscultates over the access site, feeling for a thrill or vibration and listening for the bruit or swishing sound. Presence of the thrill and bruit are normal findings, indicating patency of the access. Decreased or absent thrill and/or bruit indicates a that there is an issue with the patency of the access, which could be a result of narrowing or clotting of the access, resulting in poor blood flow. No report of pain, redness, or swelling is a normal finding. A trace of edema is not a priority.

Answer 130

C RATIONALE: c. Pelvic floor exercises (Kegel exercises) may help a patient regain control of the micturition. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. Due to risk for infection, an indwelling catheter is the last choice of treatment.

Answer 131

A RATIONALE: a. Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine; the nurse educates the patient to expect this change.

Answer 132

A,E,F RATIONALE: a, e, f. Maintaining free urinary drainage is a nursing priority. Institute measures to prevent the tubing from becoming kinked and urine from backing up in the tubing. The catheter should be allowed to drain freely through tubing that is not kinked. Nursing care of a patient with a urinary sheath includes skin care to prevent excoriation. Remove the condom daily and wash the penis with soap and water, and dry it carefully. Care must be taken to fasten the sheath securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. The tip of the tubing should extend 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area. Confining a patient to bedrest increases the risk for hazards of immobility.

Answer 133

B RATIONALE: b. The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient (ANA, 2014; SUNA, 2015). The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16Fr gauge commonly used (Bardsley, 2015a; Beauchemin et al., 2018; Newman, 2013). A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise (ANA, 2014).

Answer 134

A,C,D,E RATIONALE: a, c, d, e. The nurse gives these instructions to collect the midstream/clean-catch urine specimen: Wash your hands with soap and water. Open the collection cup, and place the lid face up; do not touch the inside. Separate the labia and cleanse the urinary opening with soap and water or towelettes included in the kit. Void about 1 oz. (30 mL) into the toilet, then move the collection cup close to the urinary opening and void about 1 oz (no less than 2 teaspoons) into the container. Pass the remainder of the urine into the toilet. Without touching the inside of the lid, close the cup and return it to the nurse.

Answer 135

B RATIONALE: b. Urinary incontinence of urine past the age of toilet training is termed enuresis. Hospitalization may cause regression of toileting habits.

Answer 136

B RATIONALE: b. Nephrotoxic medications are those capable of causing kidney damage. The nurse can assess I&O, quality of the urine, and renal function blood tests to detect this problem. Urinary frequency, incontinence, and getting up at night to void (nocturia) are not effects of nephrotoxic medications.

Answer 137

A RATIONALE: a. The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility.

Answer 138

C RATIONALE: c. If the patient reports severe cramping with introduction of an enema solution, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate is too fast, severe cramping may occur. The head of the bed may be elevated 30 degrees for the patient’s comfort if the patient needs to be placed on a bedpan in the supine position while receiving the enema.

Answer 139

A,B,F RATIONALE: a, b, f. Decreased or absent bowel sounds—documented only after listening for in the epigastric and umbilical area of the abdomen for 2 minutes or longer (Bickley et al., 2021)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction.

Answer 140

B,E,F RATIONALE: b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate, metformin, or antacids containing magnesium. Opioids, diuretics, and dehydration may lead to constipation.

Answer 141

C RATIONALE: c. Instruct the patient to retain the enema solution for at least 30 minutes or as indicated in the manufacturer’s instructions. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on their left side as dictated by patient condition and comfort.

Answer 142

D,E,F RATIONALE: d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage intake of dark-green vegetables for their chlorophyll content, which helps to deodorize the feces. Explain that patients with ileostomies may tend to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.

Answer 143

A RATIONALE: a. If possible, a low-residue diet (low fiber) should be followed several days before the procedure, although some may have a full liquid diet the day before the procedure. There are multiple types of bowel preps for this procedure; the health care provider determines the best regimen for the individual. The prep is usually given as a split dose, with half being given the night before and rest the morning of the procedure. It is recommended the second dose be given at least 5 hours before and completed at least 2 hours before the study. Occasionally, some patients may receive the prep the same day as the procedure, especially if it is scheduled for later in the day. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper GI and small-bowel series of tests.

Answer 144

C RATIONALE: c. When a patient reports dizziness, lightheadedness, nausea, and/or vomiting during digital stool removal, the nurse recognizes the vagus nerve may have been stimulated. The nurse should stop the procedure, assess heart rate and blood pressure, and notify the health care provider.

Answer 145

D RATIONALE: d. A fecal occult blood test is performed first to detect GI bleeding. Lower GI barium studies should be performed next to visualize GI structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper GI series because retained barium from an upper GI series could take several days to pass through the GI tract and obscure anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them.

Answer 146

A,B,D,E,F RATIONALE: a, b, d, e, f. Care of a patient with an NG tube connected to suction includes verifying placement before administration of any fluids or medications to avoid aspiration. Radiographic evidence of the tip of the tube in the stomach, measurement of tube length, measurement of tube marking, measurement of aspirate pH, and carbon dioxide monitoring may be used. The nurse irrigates the tube with 30 mL of saline solution (or as prescribed/ per policy) with an irrigating syringe. The nurse separates the tube from the suction device, clamps the NG tube to prevent gastric secretions from leaking, and places the tip of the syringe in the tube to gently insert the saline solution. The nurse should not place irrigant in the blue air vent of a Salem sump or double-lumen tube; rather, the nurse should instill air through the vent. The air vent decreases any pressure that has built up in the stomach during suction; instilling air promotes drainage. The air vent should be placed above the stomach. Abdominal distention may indicate lack of proper drainage or delayed return of GI function. The nurse documents all irrigation and NG tube output with the I & O. If the nurse allows the irrigant to drain out, that is excluded from intake.

Answer 147

D RATIONALE: d. The nurse follows the steps of the nursing process to plan care. First the nurse assesses the patient’s bowel movements including frequency, consistency, shape, volume, and color. Based on the assessment findings, the nurse may recommend 3 of fluid daily or administer an enema, as appropriate. The nurse also monitors bowel sounds, teaches about specific foods that promote bowel regularity, ensures privacy, and encourages adequate fluid intake.

Answer 148

A,D RATIONALE: a, d. The nurse discusses signs and symptoms of colon cancer including rectal bleeding or blood in the stool, persistent change in bowel pattern or consistency of stool, persistent cramping or pain in lower abdomen (or gas), a feeling of incomplete bowel emptying, weakness or fatigue, and unintentional weight loss.

Answer 149

B RATIONALE: b. Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, postradiation damage to the bowel, diverticulitis, and Crohn disease (Kent et al., 2015).

Answer 150

C RATIONALE: c. If the stoma protrudes into the bag after changing the ostomy appliance, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

Answer 151

A RATIONALE: a. Certain saline osmotic laxatives can lead to fluid and electrolyte imbalances and should not be used in older adults and those with kidney or cardiac disease.

Answer 152

C RATIONALE: c. Hypertonic phosphate and sodium citrate solution enemas are avoided in patients with renal impairment or reduced renal clearance due to their inability to adequately excrete phosphate. This can result in hyperphosphatemia (Dougherty & Lister, 2015, as cited in Mitchell, 2019b, p. 154).

Answer 153

C RATIONALE: c. The guaiac fecal occult blood testing (FOBT) is used to detect occult blood in the stool. It is used for initial/early screening for disorders such as cancer and for GI bleeding in conditions such as ulcer disease, inflammatory bowel disorders, and intestinal polyps (MedlinePlus, 2020). A positive FOBT result indicates that abnormal bleeding is occurring somewhere in the digestive tract.

Exam 2 (Ch 7, 13-19, 29, 33, 37-39) Practice Questions Flashcards

(177 cards)